CHAOS IN DR LYNN’S CLINIC
QI Assignment 1: Complete a Value Stream Map
Read Chapter 3 in Delisle carefully “Principle 2: Map the Value Stream”. I note specific pages from these readings in the instructions below to assist you with each section of this assignment.
In this assignment complete the following steps:
Identify a healthcare process. See the example in :”Chapter 3 Principle 2: Map the Value Stream” (see attachment in Week 3). The process can include a patient, such as the example of a patient visit for a PCP exam. Or, it may include a process that does not involve a patient, such as a process for completing lab work. Ideally, you will select a process that you can observe in your current place of employment. If you are not employed, think of a past job you had and an example of a process in that setting.
If you have no experience working in healthcare, then you can use the fictional case study “Case Study with data for Assignment 1: Value Stream Map for Dr. Lynn’s clinic” below. This case study is based on the example of a patient who makes a visit for a PCP exam and then is referred to a Behavioral Health Consultant (BHC) for a “warm handoff” (meaning the physician walks the patient to the BHC in a clinic exam room, introduces patient to the BHC, and leaves the patient with the BHC for an evaluation).
Case Study with data for Assignment 1: Value Stream Map for Dr. Lynn’s clinic
Instructions: Read this case study carefully. All of the data needed to complete the value-stream map formulas are included in the case study. Your job is to create a value stream map of the current state based on this case study.
We met Dr. Lynn last weekJ. She works in a busy urban primary care clinic staffed by an administrative assistant, a scheduler, four PCP’s, two nurses, a physician assistant (PA), a medical assistant (MA) and a nutritionist. Dr. Lynn has decided to create a value stream map for process of a patient visit to the PCP, including a warm handoff to the BHC (Dr. Lynn).
Dr. Lynn consulted with all of the staff and identified a basic process map of each step from the time a typical patient first walks in the clinic door until the time the patient walks out of the clinic. Dr. Lynn completed a walk of the process from start to finish to complete the value stream map. All of the times below are based on averages provided by the staff. The times for each process step includes the estimated initial First Pass Yield (PPY) percentage in parenthesis. Dr. Lynn determined the FPY for each process step based on feedback from the team member who is most expert on that step (e.g., administrative assistant for check in, PCP for PCP interview, etc.).
All patients complete the My Own Health Report (MOHR) as part of their annual physical exam. If one is not on record the administrative assistant will instruct the patient to complete it in the waiting room after check-in using an office tablet. The physician reviews the MOHR during the patient annual physical exam, but usually not during other visits. Dr. Lynn reviews the MOHR for each new patient. Dr. Lynn will also have the patient complete the full PHQ-9 and GAD-7 if the PHQ-4 that is part of the MOHR is positive. She does this in the session with the patient using a tablet for automatic scoring and feedback. Dr. Lynn may use other rating scales or patient education, self-monitoring or other forms based on the presenting problem and treatment approach. The clinic has an Electronic Health Record (EHR) system and all staff enter notes and data for all encounters.
From the time the patient enters the office and approaches the nurses station it is one minute. The check-in with the receptionist takes 4 minutes (FPY: 97%). The patient then waits in the waiting room for 14 minutes. Then the patient is called in to compete vitals with the PA, that takes 5 minutes (FPY: 95%). The patient returns to the waiting room and waits an average of 12 minutes. Then the patient is called into the examination room for the nurse interview. The nurse interview takes 4 minutes (FPY: 90%). Then the patient waits in the examination room for an average of 17 minutes until the PCP arrives for the PCP examination. The PCP examination takes 12 minutes (FPY: 90%). The PCP then walked the patient to Dr. Lynn’s examination room and introduced the patient to Dr. Lynn. This takes 2 minutes. Dr. Lynn then completes the BHC interview that takes an average of 20 minutes (FPY: 85%). Upon completion of the BHC interview the patient returns to the nursing station to check out. Then the patient leaves the office. The clinic is relatively small, so the average time to walk from waiting room to any exam room is one minute.
Dr. Lynn made several observations during her consultation with the staff and during the process walk. First, Dr. Lynn identified the following high-level process steps:
Dr. Lynn also noted the following problems that appeared to contribute to lower First Pass Yield (FPY) for each step. That is, problems in each step that resulted in the process step not being completed correctly the first time. During the check in the administrative assistant often forgot to ask patients who were there for their annual physical exam to complete the MOHR. During the nursing interview and physician exam the MOHR results were usually reviewed by the nurse and PCP with the patient. However, the MOHR was not routinely re-administered while the patient was in treatment as a measure of treatment progress and reviewed by the nurse or physician. Dr. Lynn wondered if this should be an area of improvement. During the nursing interview and PCP exam Dr. Lynn observed that patients were not routinely asked about medication side effects. She thought that this may be an area of quality improvement. During the physician exam the PCP’s typically did not review the MOHR on record for patients who were there for a sick visit.
Each PCP had their own approach to identifying the need for integrated behavioral health referral to Dr. Lynn. Dr. Lynn suspected that the decision-making processes for identifying and referring patients to her were not consistent between the PCP’s and may be an area of improvement. Dr. Lynn also observed that sometimes patients were not clear why they were referred to see her in the warm handoff. Patients reported not being clear on her role and purpose if the referral. Dr. Lynn identified the need for improved patient information on her service and perhaps a script for PCP’s would be a potential area of improvement. During her own patient visits Dr. Lynn noticed that she often spent too much time going over the MOHR and other rating scales she administered, leaving her feeling rushed to transition to the treatment planning, advising and assisting the patient to leave with a clear and agreed upon plan of action for behavioral issues. Dr. Lynn reviewed the wait times between each process step and did not think that they were excessive for a busy clinic. However, she realized that she had not reviewed the clinic patient satisfaction data available on this topic. In addition, Dr. Lynn noted that while there were some magazines in the waiting room, they were older only a few subscriptions were available. She thought that having magazines in the exam rooms may also be helpful, and she wondered if a TV added to the waiting room would be helpful.
Complete a Value Stream Map. Begin with a process map of the current state (see pages 33-35). The current state is the process as it currently stands; what actually takes place, not what should take place. The map should include a high-level process map and a midlevel process map. Include the time spent waiting in between steps in the process map.
TIPs for completing a Value Stream Map
Lucidcharts is the recommended software for completing the Value Stream Mapy. You may also useMicrosoft Word or Powerpoint: Go the to the “SmartArt” tab and select “Process”. Experiment creating the high-level and mid-level by adding process steps for SmartArt. Open the “text panel” to add more steps in the process. Experiment with using this tool.
Estimate the cycle time needed to complete each step in the process map. Cycle time is the time needed to complete a specific process step. See Figure 3.7 on page 36.
Calculate a First-Pass Yield (FPY) for each step in the process and the overall process FPY yield. See page 37. The FPY is simply an estimate of the percentage of time that a process step is performed correctly the first time. Examples: Checking in with the receptionist, completing a PHQ-9 depression screen, having vital signs taken. The overall FPY is calculated by multiplying each individual step FPY (see Figure 3.8 page 37).
Evaluate Value Added (VA) versus Non-Value Added (NVA) activity for each process step. Carefully read the section “Identify Waste” in Delisle “Executing Lean Improvements” Chapter 2 pages 17-27 . Identify 3 key categories of VA and NVA based on the definitions in this section:
1. “VA activities” = activities that performed during the production or delivery of the service that increase it’s value to the customer.
2. “NVA required” = NVA activities performed during the production or delivery of a service that use time and resources but do not increase value to the customer, but are required due to legal, regulatory, accreditation or other requirements.
3. “Waste” = NVA activities performed during the production or delivery of a service that use time and resources but does not increase value to the customer and is not required for legal, regulatory, accreditation or other reasons.
a. There are 8 types of Waste using the mnemonic DOWNTIME (see pages 17-27 in Delisle)
iv. Not utilizing peoples abilities
viii. Excess processing
Complete VSM Calculations (See box on top of page 44)
1. Cycle time
2. Wait time
3. Lead time
4. Value-adding ratio (VA time)/(Lead time)
5. First-pass yield: multiple every process step FPY
Identify opportunities for improvement based on the FPY and NVA activities. This section of the assignment should be a written narrative summary. Use the “Case Study” example on page 57 in Delisle as an example. Simply describe what process improvements you have identified based on the VSM that can improve cycle time and decrease waste. Do include the VSM steps and calculations to identify problem areas and propose solutions in this narrative. Be brief and do not go into excessive detail on your plan for improvement. A more detailed plan will be required in QI Assignment #2 in this class when you complete a PDSA. This written narrative should be 1 – 2 pages in length. Use APA Style and good grammar for narrative sections. References are not required for this narrative. However, if you would like to add a relevant reference you may do so.
Value Stream Map Delisle Executing Lean Ch .pdf